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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - January 2014

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RARE Report

The RARE Report updates participating hospitals and Community Partners on news and events related to the RARE Campaign, demonstrates how hospitals and Community Partners can work together across the continuum of care, shares best practices, and provides tools to keep all stakeholders engaged and implementing improvements to achieve RARE goals. Please send your feedback to: Mary Beth Schwartz.

Previous Issues

In This Issue

  1. Upcoming Events
  2. Care Transitions Intervention: Collaborative Opportunity
  3. RARE Collaborative on Mental Health Care Transitions Set to Begin
  4. Campaign Poster Gets Attention at IHI’s Annual Forum
  5. Other News
  6. Strategies at New Primary Care Clinic Reduce Avoidable Hospital Readmissions for Patients With Complex Medical Histories

Upcoming Events and News


Details and registration for all events listed below are available on the calendar page of the RARE Campaign website.

RARE Webinar: Team Care For Chronic Disease Patients: Using Lay “Care Guides”
Friday, February 21, 2014, 1 – 2 p.m. CT
Allina Health and the University of Minnesota designed and implemented a randomized-controlled trial of more than 2,100 chronic disease patients that integrated trained laypersons called “care guides.” This approach to team care was proven to be a pragmatic way to improve care quality at a reasonable cost in the primary care setting. Register by Tuesday, February 18, 2014. Register. Learn more.


Care Transitions Intervention: Collaborative Opportunity
As part of the Partnership for Patients Hospital Engagement Network (HEN), the Minnesota Hospital Association, in partnership with the RARE campaign, is pleased to offer a Care Transitions Collaborative training session for committed hospitals. The training will be held June 18 and 19, 2014 in Minneapolis.

MHA logoThe Care Transitions Collaborative will support hospitals and their community partners in implementing the Care Transitions Intervention. Dr. Eric Coleman and his team designed the Care Transitions Intervention in response to the need for a patient-centered, interdisciplinary intervention that addresses continuity of care across multiple settings and practitioners. The overriding goal of the intervention is to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home. The RARE Campaign sponsored two other Care Transitions Intervention collaboratives in 2012 with participants from across the state. Additional information is available on the RARE website.

Participating organizations must commit to:

  • Plan to implement the Care Transitions Intervention in 2014
  • Participate in required pre-implementation activities
  • Allocate required resources to support program success
  • Coordinate and align care transitions work with other activities aimed at reducing avoidable readmissions

RARE Collaborative on Mental Health Care Transitions Set to Begin
The RARE Collaborative: Mental Health Care Transitions, a yearlong learning collaborative for organizations with inpatient mental health units, begins this month. It is designed to support the organizations in reducing readmissions for these patients and improve their transition into post-acute care.

Using best and promising practices as well as evidence-based interventions, each organization’s team will be coached through the process of improvement. The collaborative will primarily use virtual meetings with a daylong session at the beginning and end of the collaborative. Content will focus on the five key areas known to reduce avoidable readmissions. Participating organizations, listed below, will network with each other and learn from national experts:

  • Essentia Health East, Duluth
  • Fairview Southdale Hospital
  • Hennepin County Medical Center
  • North Memorial Medical Center
  • Regions Hospital
  • St. Cloud Hospital
  • St. Luke’s, Duluth
  • State of Minnesota/Anoka-Metro Regional Treatment Center and Community Behavioral Health Hospital - Rochester
  • United Hospital
  • University of Minnesota Medical Center, Fairview

IHI posterFor additional information, contact ICSI’s Kathy Cummings at 952-814-7086.

RARE Campaign Poster Gets Attention at IHI's National Forum
The Institute for Healthcare Improvement's (IHI) annual National Forum is an event that draws nearly 6,000 health care leaders, executives and others from around the world. At the 2013 Forum, we again had the opportunity to display a storyboard sharing the great work of the RARE Campaign. Interest in the campaign was high and viewers were intrigued with the collaboration and support for the campaign throughout the state of Minnesota. View the storyboard.


American Lung Association Learning Collaborative to Reduce COPD-Related Readmissions
The American Lung Association in Minnesota is facilitating a one-year learning collaborative to help hospitals reduce avoidable readmissions related to chronic obstructive pulmonary disease (COPD). Great accomplishments and lessons were learned in the 2013 cohort, which included New Ulm Medical Center, Sanford Health Care in Fargo, St. Francis Medical Center, United Hospital, and Unity Hospital. Processes established and lessons learned included patient risk stratification, in-patient staff education, ideal in-patient therapies, medication reconciliation, role of the primary care provider, patient follow-up, and transition of care. Numerous tools for providers and patients were developed and are available to participants.

The second cohort will begin in March 2014. Hospitals will gather for in-person meetings six times during the one-year collaborative. There will also be monthly updates and technical assistance calls.  For more information, please contact Jill Heins-Nesvold, director of respiratory health at the American Lung Association in Minnesota.

MAPS logoMAPS Developing Tools to Help Patients Take a More Active Role in
Managing Their Health Care Transitions

One of the most challenging aspects of the health care journey remains at care transitions - moving from one care setting to another. The Minnesota Alliance for Patient Safety (MAPS) is excited to start work on a subcontract to improve the safety of care at transitions through better engagement of patients, residents, families and consumers. This subcontract comes to MAPS through an expansion of MHA's Hospital Engagement Network (HEN) contract with the Centers for Medicare and Medicaid Services.

The initiative's goal is to identify effective ways to engage health care consumers in taking a more active and informed role in the management of their health care transitions to reduce potential harm. The grant work will focus on how to activate patients so that they can prevent harm at transitions, including medication reconciliation, communicating test results, understanding the warning signs that a medical condition is worsening, and completing next steps or follow-up appointments.

MAPS will work with its member organizations, oversee the project and engage local subcontractors to accomplish the proposed work. The initiative will have two phases. The first will be the development of a tool that patients will use to guide a safe care transition. In the second phase, MAPS will seek to educate consumers on the importance of playing an active role in their health care and evaluate the effectiveness of the messages and tools developed.
MAPS plans to work with local health care organizations to pilot and test the consumer engagement tool. If your organization would like to help with this testing, please email MAPS or call 612-362-3756.

MDH logoe-Health and Health Information Exchange Toolkits and Trainings
for Community Partners

Hospitals working beyond their walls to reduce readmissions may want to inform their partners of new tools and January trainings to facilitate understanding of the state’s e-health mandate and how to accelerate e-health adoption and participation in health information exchange. The trainings will introduce four newly developed Health Information Technology Toolkits for Behavioral Health, Home Health, Local Public Health and Social Services, developed by Stratis Health and funded by the Minnesota Department of Health. Learn more.

Coordination of Care Central to Preventing Hospital Readmissions
A new survey examining how U.S. hospitals are addressing the Centers for Medicare & Medicaid Services 30-day readmission penalties found that most facilities agree on what core strategies work the best for reducing preventable readmissions. (Healthcare Finance News, November 7, 2013)

Patients Engaged in Their Care Have Lower Readmission Rates
Patients who lack the knowledge, skills, and confidence to manage their own care after hospital discharge have nearly twice the rate of readmissions as patients with the highest levels of engagement, Boston Medical Center researchers have found. (Medscape, October 29, 2013)

Primary Care Physician Communication at Hospital Discharge Reduces Medication Discrepancies
Primary care physician (PCP) communication with patients within 24 hours of discharge was associated with decreased medication discrepancies. The study’s results further demonstrate the importance of PCP involvement in the hospital discharge process. (Journal of Hospital Medicine, November 1, 2013)

The Readmission Risk Flag: Using the Electronic Health Record to Automatically Identify Patients at Risk for 30-Day Readmission
An automated prediction model was effectively integrated into an existing EHR and identified patients on admission who were at risk for readmission within 30 days of discharge. (Journal of Hospital Medicine, November 13, 2013)

Readmissions for Medicare Patients Fall for Second Year
Preventable readmissions for Medicare patients are on the decline as a result of the Affordable Care Act, according to a blog post from the Centers for Medicare & Medicaid Services (CMS). After remaining consistently at 19 percent from 2007 to 2011, readmissions for Medicare beneficiaries fell to 18.4 percent in 2012, representing 70,000 fewer readmissions. The downward trend continued in 2013, according to the post, with preliminary claims data indicating that the readmission rate dropped below 18 percent in the first eight months of the year, with 130,000 fewer readmissions between January 2012 and August 2013. (Fierce Healthcare, December 9, 2013)

Strategies at New Primary Care Clinic Reduce Avoidable Hospital Readmissions for Patients With Complex Medical Histories

Courage Kenny Rehabilitation Institute is a RARE Community PartnerAllina Health Courge Kenny logo

While Courage Kenny Rehabilitation Institute’s goal is to help individuals realize their full physical potential through a host of cutting edge rehabilitation services, it wasn’t until 2010 that a primary care clinic was available on the facility’s Golden Valley campus. In the three years since it opened, that clinic has proved to be key in helping patients avoid unnecessary readmissions to acute care hospitals.

In 2009, Courage Kenny, then called Courage Center, received a planning grant from the Minnesota Department of Human Services to begin research on the benefits of starting a primary care clinic on its campus. Courage Center had physiatry and psychiatry clinics, but clients were frequently asking for primary care services, too.

The clinic, called Courage Kenny Rehabilitation Institute Advanced Primary Care Clinic, became a health care “home,” a primary care initiative from 2008 health reform. Clinics that are health care homes link primary care providers with patients and families to improve outcomes for individuals with more serious or chronic medical problems. In Courage Kenny’s clinic, patients have complex medical histories that typically include as many as 10 to 12 secondary medical conditions along with their primary disabilities. Many patients also have a mental health diagnosis. 

“Social supports for our patients are often very fragile,” explained Nancy Flinn, occupational therapist and senior scientific advisor at Courage Kenny. “They may live in assisted living facilities, subsidized housing or must rely on a personal care attendant. They appreciate that primary care services are conveniently available and accessible on our campus.”

As part of RARE, Courage Kenny’s clinic implemented several strategies to reduce hospitalizations for their patients. These included having clinic care coordinators:

  • Make post-hospital calls to patients where they can help answer questions and provide needed support.
  • Arrange for transportation to clinic visits or for other wellness needs.
  • Accommodate telemedicine visits, when possible, to avoid the disruption that an in-clinic appointment can cause.
  • Work with the clinic physicians and other care professionals to create a thorough care plan that includes information on the nuances of the accompanying medical conditions.
  • Assist with medication management for patients who are taking nine different medications, on average.

“Our clinic care coordinators, who are registered nurses and social workers, maintain regular contact with patients after a hospital discharge,” said Heidi Street, MD, medical director of the clinic and transitional rehab program at the Golden Valley campus.  “Having this background helps the care coordinators acquire a full understanding of the patients’ needs and helps them link the patients with community-based services so they can cope with life while working toward better health.”

The results have reduced the 30-day hospital readmission rate from 42 percent to an impressive 17 percent. “This is huge for the quality of life for our patients,” said Dr. Street. “We’re excited about this improvement and about meeting the primary care needs of our patients. They can receive care from professionals who already know the intricacies of their situations. Patients know their caregivers are working on their behalf to help them avoid hospitalizations and set-backs.”

For additional information, contact Nancy Flinn, Courage Kenny, at 763-520-0210.

The RARE Report is brought to you by the RARE Campaign’s Operating Partners: Institute for Clinical Systems Improvement, Minnesota Hospital Association and Stratis Health, with contributions by the campaign’s Supporting Partners, Minnesota Medical Association, MN Community Measurement and VHA Upper Midwest.

If you have any questions related to the content of the RARE Report, contact:

Patients and family members
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RARE is a campaign lead by the Institute for Clinical Systems Improvement, the Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.